Provider Demographics
NPI:1962556514
Name:PINES FAMILY DENTAL
Entity type:Organization
Organization Name:PINES FAMILY DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:LIZASO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-430-1717
Mailing Address - Street 1:20170 PINES BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1202
Mailing Address - Country:US
Mailing Address - Phone:954-430-1717
Mailing Address - Fax:954-430-3049
Practice Address - Street 1:20170 PINES BLVD STE 108
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-1202
Practice Address - Country:US
Practice Address - Phone:954-430-1717
Practice Address - Fax:954-430-3049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0014961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty